Treatment of low flow, indirect cavernous sinus dural arteriovenous fistulas with external manual carotid compression - the UK experience.

Introduction: External manual carotid compression (EMCC) is a treatment option for indirect cavernous sinus dural arteriovenous fistulas (CS-DAVF). The exact mechanism of how this works is unclear but compression of the carotid and jugular produces thrombus in the cavernous sinus (CS). Although compression of the superior ophthalmic vein (SOV) has been described as a treatment option this technique is not always amenable. We studied the clinical features, imaging studies, complications and resolution of CS-DAVF in a series seven patients.Materials and methods: Between 2011 and 2017 we treated 7 patients (4 female, 3 male, age range: 60-86 years) with EMCC for an indirect, low-flow CS-DAVF (Barrow B-D). Patients compressed the cervical carotid artery on the side of the CS-DAVF using the contralateral hand for 5-10 seconds 5-10 times per day. Using gradually increasing pressure they compressed the carotid artery and jugular vein until the pulse was no longer palpable.Results: 6 patients had complete resolution of their CS-DAVF within a range of 5-24 months of symptom onset (median 8 months). 5 of our patients had complete resolution of their clinical symptoms at final follow-up. One patient had a failed endovascular procedure, and subsequently underwent surgery to cannulate the SOV for a transvenous endovascular approach to the fistula but in the meantime she had performed EMCC, which is thought to have resolved the fistula. One patient remains under follow-up and is performing EMCC.Conclusion: EMCC is a safe and low risk technique for low-flow indirect CS-DAVF and should be considered as a first line treatment for patients unable to have endovascular treatment. Although compression of the SOV has been described this can often be difficult to perform in the context of periorbital oedema. EMCC should always be performed using the contralateral hand, because this will ensure that the compressing hand falls away should cerebral ischaemia develop.

Observed rupture of unruptured intracranial aneurysms.

Aim: To study the aneurysms where pre and post-rupture imaging was available to determine the impact of rupture on morphology and size of the aneurysm.Methods: A retrospective case series where all cases of ruptured aneurysms over a 5-year period were evaluated and cases identified where pre and post rupture imaging was available. These were then studied in detail.Results: The actual change in the volume of the aneurysm pre and post rupture was quite small and the underlying shape/morphology did not change at all.Conclusion: Post-rupture morphology of aneurysms can be used as representative of pre-rupture morphology. Further larger studies in collaboration with other neurosurgical centres to corroborate this view would be helpful.

Inversion therapy in patients with pure single level lumbar discogenic disease: a pilot randomized trial.

PURPOSE: Backache and sciatica due to protuberant disc disease is a major cause of lost working days and health expenditure. Surgery is a well-established option in the management flowchart. There is no strong evidence proving that traction for sciatica is effective. We report a pilot prospective randomized controlled trial comparing inversion traction and physiotherapy with standard physiotherapy alone in patients awaiting lumbar disc surgery. This study sought to study the feasibility of a randomized controlled trial on the effect of inversion therapy in patients with single level lumbar discogenic disease, who had been listed for surgery. METHODS: This was a single centre prospective randomized controlled trial undertaken at the Regional Neurosciences Centre, Newcastle Upon Tyne, UK. It was a prospective randomized controlled trial where patients awaiting surgery for pure lumbar discogenic disease within the ambit of the prestated inclusion/exclusion criteria were allocated to either physiotherapy or physiotherapy and intermittent traction with an inversion device. Post-treatment assessment made by blinded observers at 6 weeks for various outcome measures included the Roland Morris Disability Questionnaire (RMDQ) Score, Short Form 36 (SF 36), Oswestry Disability Index (ODI), Visual Analogue Pain Score (VAS), magnetic resonance imaging (MRI) appearance and the need for surgery. Avoidance of surgery was considered a treatment success. RESULTS: Twenty-six patients were enrolled and 24 were randomized [13 to inversion + physiotherapy and 11 to physiotherapy alone (control)]. Surgery was avoided in 10 patients (76.9%) in the inversion group, whereas it was averted in only two patients (22.2%) in the control group. Cancellation of the proposed operation was a clinical decision based on the same criteria by which the patient was listed for surgery initially. There were no significant differences in the RMDQ, SF 36, ODI, VAS or MRI results between the two groups. CONCLUSION: Intermittent traction with an inversion device resulted in a significant reduction in the need for surgery. A larger multicentre prospective randomized controlled trial is justified in patients with sciatica due to single level lumbar disc protrusions. [ IMPLICATIONS FOR REHABILITATION: • Resolution of impairment and diasability due to radiculopathy is the aim of any intervention.• Avoidance of surgery meant satisfactory resolution of impairment and disability due to radiculopathy. This happened more often in the inversion group to the extent of reaching statistical significance.• The 12-point improvement in disability by the Oswestry Disability Index in the inversion group suggests a role for this intervention in disability reduction.• Inversion may form part of the conservative rehabilitation of patients with single level unilateral lumbar disc protrusion alongside other forms of physiotherapy.• There is a potential secondary impact in the reduction of rehabilitation following surgery.]

Image-guided drainage of cystic vestibular schwannomata.

The management of vestibular schwannomata is controversial. Surveillance remains an acceptable option for elderly patients or those with small lesions. Stereoradiosurgery is also an option, while surgery is often preferred in younger patients with larger lesions. In elderly patients with lesions causing brainstem compression, craniotomy is a major undertaking. We report two cases of cystic cerebellopontine angle tumours in patients with co-morbidity, who were managed successfully with image-guided insertion of a cystoperitoneal shunt.

Intraventricular haemorrhage without subarachnoid haemorrhage due to a ruptured aneurysm.

The incidence of aneurysmal subarachnoid haemorrhage (SAH) in the UK is about 10 per 100 000 of the population per year and it is a potentially fatal condition. Prompt recognition and referral to a neurosurgical unit is crucial for a better outcome. A typical history of sudden severe headache, CT scan and sometimes a lumbar puncture would help clinch the diagnosis. Though intracerebral haemorrhage (ICH) and intraventricular haemorrhage (IVH) are not uncommon after an aneurysmal rupture, ICH and/or IVH without SAH are rare (<2%). In such cases, a high index of suspicion is needed to deliver the correct management. This report describes a case of posterior communicating artery aneurysm presenting with pure IVH on CT. The aneurysm was diagnosed by performing a CT angiogram and the patient underwent a successful coil embolisation.